Hello Friends and Family,
It has been quite some time since I sent out a letter. I have now traveled to Malawi to visit my sister for a few weeks and cover for a surgeon who is on vacation. So the next group will be from my time in Malawi.
Everyones question was, how long does it take to get to Malawi? Where is Malawi? Well I left, driving to Portland at 11 AM Friday. I arrived in Malamulo Malawi at 10PM Sunday night. So all the intervening time was travel or wait to travel (layover). My longest flight was from Washington DC to Addis Ababa, Ethiopia- 13hrs. Cristy picked me up for the last hour trip. It is great to see her!
My first day was today, Monday. It was to be a slow day as they had not planned any surgeries for me thinking that I would be jetlagged! They had worship at 7AM, then a quick review of what happened with certain patients at 8AM. Next I started rounds with a clinical officer, Leventhani. We would see one patient, translating english into Chechewa. then back again. It was a slow process, as he didn’t know any of my patients, and we had to repeat many questions. This one had been beaten by a stranger another by a husband. dressings needed to be replaces. the dried bloody gauze was pulled from the wound and stitches and then there was no gauze to replace it. So he went searching for gauze. After about 5 minutes I couldn’t wait any longer so went looking for him. He was called to see another patient on his way and was sidetracked repeatedly. They pullled us out to check someones prostate that they felt has prostatic hypertrophy. They had prostatitis, so I treated and sent home. Another prostate exam- hypertrophy. Female bleeding for 3 years in a post menopausal woman who is HIV positive- cervical CA ?resectable? Then back to the female surgical ward. This all finished around 1PM when it was “time to eat”. I ran and grabbed a bite with the SIMS group visiting from Loma Linda, then went back. There was no one to round with so I waited.
I had seen a gentleman with a lipoma on his head so I went to the operating room and we removed that. Then there was the woman with large femeral head decubati. One side had pus draining from a large black area on her left hip. As expected, when we removed all the dead tissue the femur was exposed, with pus around the femur head. (the upper leg bone head at your hip). She has not walked for 4 months and Im quite sure she will do poorly.
After that I was asked to see a 13 year old girl that had been admitted over the weekend with abdominal peritonitis. A typhoid test had been done this morning that was normal, she had a little elevation in her white blood count and had had nausea and vomiting but no longer. I tapped on her little belly and she cried out in pain. I bumped the bed and she cried. Her abdomen was very firm. She had signs of peritonitis. I recommended to the family that we operate TODAY! They agreed so we arranged for that next, 4PM. Then there was a new admission that they wanted me to see because she had a “dead foot”.
I looked down on an 80 year old woman with two men at her bedside. This was the “Annex” or more wealthy person ward with only two patients per room and a toilet and shower in the room. She was “not talking” since morning. She withdrew to pain, I wondered if she was having a stroke from her high blood pressure 180 or septic from her dead foot. I examined the feet. pealing back the three blankets that covered her, I gazed down at a blackened foot that had open areas where her three middle toes used to be. She had been seen at a clinic and they had amputated black toes. When she looked worse they referred her to the government hospital a hour away, but they preferred to travel here. This hospital was built more than 50 years ago. And it’s reputation as a good hospital is still carried on from years past. I recommended that we remove the leg today. They agreed so I went to the theatre (operating room) for the 13 year old girl.
Judith’s young slender frame lay on the bed. She winced at every movement, and cried out when someone pulled out the gown from under her. Soon she was intubated and asleep. A urine cathater was placed with my guidance of how to keep it sterile, it had appeared the nurse was just going to insert it without cleaning at all! We covered her with some throw away paper drapes after prepping the abdomen with betadine. It is nice to operate on extremely thin people again. No excess, just skin ,then fascia, then your inside. Clear fluid came pouring out. Ascites! The small intestines were huge. She had a blockage. I felt around inside and felt the area that was large on one side and small calibar intestine on the other. A firm white mass lay between the two diameters. Cancer? Tuberculosis? “Is this patient HIV positive?” It hadn’t been done. It seems about 50% of the hospital patients are HIV positive. I decided to resect the obstructed area. I slowly made my way through the vessels feeding this part of intestine in the mid transverse colon. The pancreas near by, duodenum to the right, there’s the right kidney and ureter. I point out structures to the clinical officer who is helping me. This is his first day of assisting in surgery. I take out her large appendix which is hiding behind the cecum (beginning of large intestine). I take out the “bad” section and reconnect the two open ends with silk sutures. I put in nearly 100 sutures taking 1.5 hours. The diameter was quite large because of the dilation. At the end all looks healthy. I wrap it in her pitiful omentum (the hanging fat layer in the abdomen). I notice a small white spot of the same thing sitting on her tiny uterus. I’m suspicious of cancer, but she’s so young! I will try to convince the family to take the mass to a pathologist in Blantyre to have it evaluated so I can know in a week or two what this was. Hopefully they will agree.
After cleaning the operating room we are ready for our last surgery, the woman with a dead foot. She was wheeled in on the gurney. Transferred over to the operating room table. The anesthetist attempted to intubate (put the breathing tube) her four times. Finally they held a mask to her face and let the ventilator do it’s work. I put a tight elastic bandage on her upper thigh to make a tourniquet. Chose the area to cut then cut, deeply cut. Down to bone, tibia then fibula. They handed me the small saw, and with a back and forth motion, I cut the tibia in two. Next the fibula was snipped in two. Vessels were tied, and nerves were divided. Eventually the two edges came together covering the bone. I asked for a drain and there weren’t any. So I took a sterile glove, cut it, using it as a drain. A tight elastic bandage was placed over the stump.
After writing the one sentence surgical note, and the orderes, I looked for the clinical officer. He had already split. I realized I still had to make rounds on the male surgical ward-10 patients. I went there and found the nurse. She helped me make rounds at 10:00PM. One with head trauma after a beating, one with broken ribs after falling out of a truck while riding in the back. Another a displaced elbow for the past five days- wow that should have been reduced days ago. Another with a broken male appendage (yes that can happen when stiff). And another diagnosed with appendicitis, treated with antibiotics since there was no surgeon last week. Fortunately, today his pain is much better than it has been for the past 6 days. I make it “home” about 10:45PM. I scarf down some wonderful soup Cristy had made, shower, then lay here in bed. It’s 1AM and my brain thinks it’s 4PM. I suspect sleep with come soon, when I attempt to shut off my brain again. It’s been a good, busy day. Lord, help my patients heal!